1. health and fitness
2. disease
3. aids and hiv

CUA
The Catholic University of America
Office of Disability Support Services
620 Michigan Ave NE, 201 Pryzbyla Center
Washington, DC 20064
Phone 202-319-5211, Fax 202-319-5126
Dear Prospective Student,
In order to establish eligibility for services and to enable our staff to work more effectively with you in the provision of
services, please complete the enclosed Intake form and provide documentation of the disability as outlined by our
Documentation Guidelines. All records will remain strictly confidential and are not a part of your academic record.
The aforementioned guidelines are provided so that Disability Support Services can respond appropriately to the
individual needs of the student. We reserve the right to determine eligibility for services and modifications to programs
based on the quality of the submitted documentation. All documentation is confidential.
CONFIDENTIALITY
The University recognizes that student disability records contain confidential information and are to be treated as
such. Therefore, documentation of a student’s disability is maintained in a confidential file in DSS and is considered part
of the student’s education record. Information related to a disability may be disclosed only with the permission of the
student or as permitted by the university’s student records policy and federal law. At the same time, however, a
students' right to privacy must still be balanced against the university's need to know the information in order to provide
requested and recommended services and accommodations. Therefore, in the interest of serving the needs of the
student, the provision of services may involve DSS staff disclosing disability information provided by the student to
appropriate University personnel participating in the accommodation process. The amount of information that may be
released is determined on a case-by-case basis, and will be made in accordance with the university’s policy on student
records.
I have read and understand the above policies and agree with the terms. Sign your name indicating you composed and
wrote the responses to the questions in the form.
Signature: ______________________________________________
Name (Print): ____________________________________________ Date: ________________
All forms must be returned directly to:
Disability Support Services
The Catholic University of America
620 Michigan Ave NE, 201 Pryzbyla center
Washington, DC 20064
Phone: 202-319-5211 Fax: 202-319-5126
Email: [email protected]
IT IS STRONGLY RECOMMENDED THAT ALL FORMS AND DOCUMENTATION BE RETURNED BEFORE THE
START OF THE SEMESTER IN ORDER TO ALLOW TIME FOR PROCESSING.
_________________________________________________________________________________________
OFFICE USE ONLY
__________ Date Registration Form Received
__________ Date Intake Completed ________ By (INT)
__________ Date Documentation Received
__________ Date Additional Documentation Received
__________ Date Documentation Approved
Updated: 3/24/15
DISABILITY SUPPORT SERVICES
UNDERGRADUATE REGISTRATION FORM
In order to receive accommodations, please submit a copy of your documentation regarding your disability
with this form. Documentation guidelines are available at http://dss.cua.edu. Documentation must be
received before your registration is complete.
Date: ______________________
I
BIOGRAPHICAL INFORMATION
Name: ______________________________________________________________________________
First
Middle
Last
Student ID # _____________________ Birth Date: ________________ Gender: ___MALE
___FEMALE
Race/Ethnic Background (Optional): ______________________ Military Active or Veteran: ___ Yes ___ No
Cell Phone: ________________________ Home Phone: ________________________
Other Phone: ________________________ Mark one: ___Parent’s home
___Mom/Dad Cell
Address:
_______________________________________________________________________________
________________________________________________________________________________
City
State
Zip Code
CUA E-mail Address:
@cardinalmail.cua.edu
Alternate E-mail Address: ___________________________________________________________
II
STUDENT STATUS
First Semester at CUA:
___Fall ___Spring ___Summer
Year: ________
Anticipated Date of Graduation:
___Fall ___Spring
Year: ________
___ Undergraduate Year: ___ Freshman ___Sophomore ___ Junior ___ Senior
___ Transfer student
___ Visiting student Dates: __________ to _____________
School/Program:
___ Arts & Sciences: Major: _____________________ or ___Exploratory
___ Architecture
___ Music
___ Theology
___ Business & Economics
___ Engineering
___ NCSSS
___ Philosophy
___ Library & Information Sciences
___ Nursing
___ Metropolitan College of Professional Studies
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III
DISABILITY INFORMATION
Disability (check all that apply):
____ ADD or ADHD
Type: _______________________
____ Learning Disability: Type: ________________________
____ Autism Spectrum:
Date/Age at Diagnosis: _____________
Date/Age at Diagnosis: _____________
Type: ________________________ Date/Age at Diagnosis: _____________
____ Blind or Low Vision*
Date/Age at Diagnosis: _____________
____ Deaf or Hard of Hearing*
Date/Age at Diagnosis: _____________
____ Health
Type: ________________________
Date/Age at Diagnosis: _____________
____ Mobility*
Type: ________________________
Date/Age at Diagnosis: _____________
____ Psychological
Type: ________________________
Date/Age at Diagnosis: _____________
____ Traumatic/Acquired Brain Injury
Date/Age at Diagnosis: _____________
____ Other: ______________________________________
Date/Age at Diagnosis: _____________
*Please complete the additional sections below
Mobility (Skip if this section does not apply to you)
Level of Mobility:
• Dexterity: ___ All ___ None ___ Limited
•
Ambulatory: ___Yes ___ No ___ With minimal assistance
Do you require a personal care attendant? ___ Yes
___ No
Do you use a service animal? ___ Yes ___ No
Mobility Device Requirements:
___ Electric Wheelchair ___ Manual Wheelchair ___ Scooter
___ Other (Walker, crutches, cane, etc.)
Blind & Low Vision (Skip if this section does not apply to you)
Level of Disability
___ Total Blindness
___ Legally Blind
___ Low Vision
___ Partial vision with glasses
Do you use a Seeing Eye dog? ___ Yes ___ No
Deaf & Hard of Hearing (Skip if this section does not apply to you)
Level of Disability
___ Completely Deaf
___ Have some hearing (with aides)
___ Have some hearing (without aides)
___ Have hearing in one ear
___ Can read lips
Supports
___ Hearing Aids
___ Assistive Listening Device (FM System)
___ Interpreter (ASL)
___ Transcriber (CART)
Do you use a hearing dog? ___ Yes ___ No
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Please list any disability related medications you are taking:
Name: _____________________Purpose: _____________________Start date: __________Dosage: ________
Name: _____________________Purpose: _____________________Start date: __________Dosage: ________
Name: _____________________Purpose: _____________________Start date: __________Dosage: ________
Name: _____________________Purpose: _____________________Start date: __________Dosage: ________
Please explain how the medication helps you:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
IV
SERVICE HISTORY
If you received services at a previous institution please describe:
High School:
What was the size of your school? ___ Small ___ Medium ___ Large
Was it a school that specialized in working with students with learning disabilities?
___ Yes ___ No
Did it have Special Education/Support Services? ___ Yes ___ No
Did you use your accommodations?
___ Yes ___ No
College/University:
Name of the school: ________________________________________
City and State: ___________________________________________
Dates Attended: __________________________________________
Reason for Leaving: _______________________________________
Did you request accommodations at this institution?
YES
NO
Were accommodations provided?
YES
NO
How have services you have received previously assisted you?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
For students who receive agency services: (Skip if this section does not apply to you)
Do you currently receive assistance from any of the following?
___ Services for the Blind
___ Department of Rehabilitation Services
___ Department of Veteran Affairs
___ Other: ___________________________________
Name of Rehab Counselor: ___________________________ Email: __________________________
Agency Name: _____________________________________________________________________
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V
CURRENT IMPACT STATEMENT
Functional Limitations: Please check off the activities listed below that you believe are affected as a result of
your diagnosis. Please indicate level of limitation you experience as a result of the disability.
1= Unable to Determine
1
2
3
4
2= No Impact
5
3= Mild Impact
Major Life Activities
1
4= Moderate Impact
2
3
4
5= Substantial Impact
5
Learning / Time Management
Caring for Oneself
Memory
Talking
Concentrating
Hearing
Listening
Breathing
Organization
Seeing
Managing distractions
Timely submission of
assignments
Walking
Standing
Lifting/Carrying
Attending class regularly
Making and keeping
appointments
Sitting
Performing Manual
tasks
Managing stress
Eating
Writing
Working
Spelling
Interacting with others
Quantitative reasoning (math)
Sleeping
Processing Speed
Reading
Describe in as much detail as possible how the diagnosed condition is currently impacting you (use additional paper if
necessary).
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Describe in as much detail as possible how the diagnosed condition has or has not impacted and substantially limited
you in the past. Describe what supports you have used? (use additional paper if necessary).
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
If you have tried any medical or educational interventions to manage the diagnosed condition, please explain what
these were and how and why they have or haven’t helped (use additional paper if necessary).
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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ACADEMIC ACCOMMODATIONS RECEIVED/REQUESTING
Please check/describe any services you have received in the past under “Previously Received”.
Please check those services you are interested in requesting at CUA under “Requesting at CUA”.
Received in
High school
Received
in college
Requesting
at CUA
Classroom Accommodations:
Access to teacher handouts, slides, overheads
Additional time on in-class writing assignments
Assistive Listening Device (FM Loop)
Assistive Technology (laptop, note taking device, etc.)
Closed Caption Video
Information on board read aloud for students with visual
impairments
Interpreter/Transcriber:
ASL
CART
C-PRINT
TYPEWELL
Leave classroom when symptoms occur
Notetaker
Occasional exceptions to absentee/tardiness policy
Recorded Lectures/ Smartpen
Foreign Language Waiver or Substitution
Test Accommodations:
Additional time when taking quizzes and exams ( 1.5 or 2)
Alternate exam dates during heavy scheduling/space
between
Alternative testing environment
Assistive Technology on exams
Screen Reading Software
Voice Input Software
Other
Calculator
Computer for tests
No scantron (due to visual issues)
Scribe
Spell-check or points not taken off for spelling
Print Accommodations:
Materials in Alternative Format
Braille
Electronic (DAISY, MP3, ePub,DOC, KESI, PDF)
Large Print
Services:
Adjustable Height Table in Class
Priority Registration
Other (please explain):
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SERVICES RECEIVED/REQUESTING: (Skip if this section does not apply to you)
Received in
High school
Campus Access
Received in
college
Requesting
at CUA
Private bath
Kitchen Modifications-in suites (lowered shelves, roll-under
counters, etc.)
I cannot walk long distances quickly
I cannot walk long distances at all
I cannot go up or down stairs and need access to an elevator
Brailed Room Numbers
Raised Print Room Numbers
I use an assistive walking device that makes it difficult to get
around independently during inclement weather
I use a service animal or Emotional Support Animal
I use a cane
I will need Orientation & Mobility training
Dining Services
Assistance Needed (access to food choices help with tray,
cutting food, eating)
My medical condition requires me to be on a special diet
Other
Housing Services
Single Room (for medical issues)
Accessible Room (elevator, space for chair, equipment, lowered
shelves, rods, grab bars, lower peep hole, visual door bell, door
handles, etc.)
Bathroom Modifications (grab bars, roll in,
Bathtub, lowered sink)
Access to a Kitchen for dietary/health reasons (that cannot be
accommodated by consulting with the campus dietician)
Height of Shelves Adjusted
Door/Key Modifications
Accessible Furniture (desk, tables, bed, etc.)
First Floor Room
Visual Alarms
Emergency Evacuation
Assistance may be required to evacuate a building
Audio/Visual Alarm
Transportation
I am driving and need access to handicap parking close to my
classes
Independent use of the Metro
Para-Transit/Metro Access
OPTIONAL:
If there are additional questions pertaining to my documentation, I give DSS the right to contact the professional who
completed the evaluation to obtain further information so that we can appropriately determine eligibility of services.
________________________________________
_____________________________________________
_________________
Signature
Printed Name
Date
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